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Special Test

Bear Hug Test for Subscapularis Tear

The Bear Hug Test is a new special test that is used to diagnose subscapularis tendon tears. It was described by Johannes R H Barth in 2006 1.

See Also: Rotator Cuff of the Shoulder

How do you perform the Bear Hug Test?

  • The patient is placed in an upright standing position,
  • The patient places the palm of the hand of the affected side on the opposite shoulder with outstretched fingers and the elbow pointing forward (anteriorly to the body),
  • While the patient tries to hold this position by actively internally rotating, the examiner grasps the patient’s wrist and tries to loosen the hand from the shoulder by forcibly externally rotating the arm , pulling at right angles to the forearm to remove his hand from his shoulder.
  • To obtain the most reliable results, it is important to confirm that the patient’s fingers are extended (i.e., not wrapped over the top of the shoulder) to prevent them from generating increased resistance by grabbing the shoulder.
  • The Bear Hug Test should be compared with the other side.

What does a positive Bear Hug Test mean?

  • If there is a tear of the subscapularis tendon, especially of the upper part, the patient is unable to maintain the hold on the opposite shoulder (a positive Bear Hug Test).
  • Pain and muscle weakness in comparison with the other side suggests subscapularis tendon dysfunction (the resistance is 20% less than that of the contralateral side).

Grading of the Bear Hug test:

Grade 0Normal: absence of pain and grade 5 muscle strength
Grade IIntermediate: pain and grade 5 muscle strength
Grade IIPositive: grade 4 muscle strength
Bear Hug test Grading

Sensitivity & Specificity

The bear hug test optimizes the chance of detecting a tear of the upper part of the subscapularis tendon. Moreover, because the bear hug test represents the most sensitive test, it can be considered to be the most likely clinical test to alert the surgeon to a possible subscapularis tear.

  • Sensitivity: 60 %
  • Specificity: 91.7%

Performing all of the subscapularis tests is useful in predicting the size of the tear.

Another study by Márcio Schiefer 2 to evaluate the Bear Hug test for clinically diagnosing subscapularis tendon tears, and compare it with other maneuvers (Lift off test, Napoleon test and Belly Press test). The Sensitivity was (75 %) while the Specificity was (56 %) and accuracy was (65 %).

See Also:

Diagnostic Utility of Bear Hug Test for Identifying Subscapularis Tears:

PopulationReference StandardSensSpec+LR-LR
165 patients scheduled to undergo arthroscopic shoulder surgerySubscapularis tear diagnosed via arthroscopic visualization.19.99.19.82
68 shoulders scheduled to undergo arthroscopic shoulder surgerySubscapularis tear diagnosed via arthroscopic visualization.60.927.5.43

Several studies report that the upper and lower portions of the subscapularis are differentially activated with the belly press test and lift off test, potentially providing ancillary diagnostic utility for these tests. Although Pennock et al. showed that the subscapularis muscle was electromyographically activated disproportionately more than any other rotator cuff muscle during the belly press test and lift off test, their results indicated that the upper and lower portions of the subscapularis were not activated at different magnitudes depending on the clinical test.

Chao et al. arrived at similar results regardless of whether the test was performed at 0°, 45°, or 90° of shoulder flexion. Therefore, tests for subscapularis strength should currently be viewed as an evaluation of the entire muscle- tendon unit rather than individual regions of the muscle.

References

  1. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006 Oct;22(10):1076-84. doi: 10.1016/j.arthro.2006.05.005. PMID: 17027405.
  2. Yoon JP, Chung SW, Kim SH, Oh JH. Diagnostic value of four clinical tests for the evaluation of subscapularis integrity. J Shoulder Elbow Surg. 2013; 22(9):1186-1192.
  3. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22:1076-1084.
  4. Márcio Schiefer, Yonder Archanjo Ching-San Júnior, Sérgio Maurício Silva, César Fontenelle, Marcos Genúncio Dias Carvalho, Fabio Garcia de Faria, José Sérgio Franco: CLINICAL DIAGNOSIS OF SUBSCAPULARIS TENDON TEAR USING THE BEAR HUG SEMIOLOGICAL MANEUVER.
  5. Chao S, Thomas S, Yucha D, Kelly 4th JD, Driban J, Swanik K. An electromyographic assessment of the “bear hug”: an examination for the evaluation of the subscapularis muscle. Arthroscopy. 2008;24(11): 1265–70.
  6. Clinical Tests for the Musculoskeletal System 3rd Edition.
  7. Netter’s Orthopaedic Clinical Examination An Evidence-Based Approach 3rd Edition Book.
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